Bioprosthetic valve calcification and pseudoneointimal proliferation in bovine and ovine models

Both porcine (PX) and bovine pericardial (BP) valves have been used in the implantable Novacor left ventricular assist system (LVAS). Results from 58 chronic LVAS implants of greater than 7 days in calves and adult sheep are presented: the PX valve was used in 41 and the BP in 17. With PX valves, the maximum and mean assist durations were 161 and 54 days, respectively, in the calf and 279 and 129 days, respectively, in the sheep. The maximum and mean durations for BP valves were 93 and 38 days (calf) and 153 and 69 days (sheep). In bovine studies with PX valves, severe obstructive pseudoneointimal (PNI) proliferation in the Dacron inflow conduit was the primary cause for termination; valves exhibited moderate calcification. With BP valves, both PNI proliferation and severe valve calcification contributed to a declining pump output, leading to termination. In contrast to the bovine experience, PNI proliferation was not observed in ovine implants. BP valves still became calcified, as evidenced by a progressive decline in pump output (from about twelve weeks) and confirmed at termination. Valve calcification was minimal with the PX valves, even at 236 days. These results favor the adult ovine animal model for extended implants.

In vitro and in vivo testing of a totally implantable left ventricular assist system

The totally implantable Novacor LVAS is being tested under NIH auspices to demonstrate safety and efficacy before clinical trials. Twelve complete systems (submerged in saline at 37 degrees C) are being tested, with an NIH goal of demonstrating 80% reliability for 2 year operation with a 60% confidence level. The systems, which are continuously monitored, are diurnally cycled between two output levels by automatically varying preload and afterload. Currently, 14.3 years of failure-free operation have been accumulated, with a mean duration of 14 months. Using an exponential failure distribution model, the mean time to failure (MTTF) is greater than 8.8 years, corresponding to a demonstrated reliability (for a 2 year mission time) of 80% (80% confidence level). Recent ovine experiments with VAS subsystems include a 767 day volume compensator implant, a 279 day pump/drive unit implant and a 1,448 day BST implant. The last 12 chronic pump/drive unit experiments had a mean duration of 153 days (excluding early postoperative complications). This compares favorably with the NIH goals for complete systems (5 month mean duration). Complete system experiments are currently underway.

Sawtooth profile fringes with a two-grating interferometer

The theory of fringe formation of arbitrary profile in a two-grating interferometer is developed emphasizing sawtooth profile fringes. Two methods of fringe synthesis are given: the spatially incoherent illumination method, leading to a coherent synthesis and the temporally incoherent (polychromatic) illumination method, leading to an incoherent synthesis.

The purification and characterization of a phospholipase A in hamster heart cytosol for the hydrolysis of phosphatidylcholine

Phospholipases A1 and A2 catalyze the hydrolysis of acyl groups of phospholipids at C-1 and C-2, respectively. These phospholipases are important in phospholipid catabolism and the remodeling of the acyl groups of phospholipids. Phospholipase A from hamster heart cytosol was purified by a combination of ion-exchange and gel filtration chromatography. The purity of the enzyme was assessed by nondenaturing polyacrylamide gel electrophoresis, two-dimension polyacrylamide gel electrophoresis, and immunological studies. The purified enzyme exhibited both phospholipase A1 and A2 activities toward phosphatidylcholine and had the ability to hydrolyze the acyl groups of phosphatidylethanolamine. However, the enzyme was not active toward lysophosphatidylcholine, diacylglycerol, or triacylglycerol. By Sepharose 6B chromatography, the molecular weight of the purified enzyme was estimated to be 140,000. Analysis of the purified enzyme by sodium dodecyl sulfate-polyacrylamide gel electrophoresis revealed that the enzyme was composed of identical Mr 14,000 subunits. At least six subunits in the native enzyme could be cross-linked by dimethyl suberimidate. Both phospholipase A1 and A2 activities showed similar pH profiles, exhibited no absolute requirements for divalent metallic cations, but displayed a high degree of specificity for the acyl groups of phosphatidylcholine at both C-1 and C-2. The Km of phospholipases A1 and A2 for 1-palmitoyl-2-arachidon-ylglycerophosphocholine was found to be identical (0.5 mM).

Amniotic band sequence and its neurocutaneous manifestations

Six new cases of the amniotic band sequence with a wide spectrum of defects were studied with respect to neurocutaneous manifestations, including histopathologic characteristics. Fetuses 1 and 2 were stillborn. Despite severe craniofacial involvement, infants 3 and 4 survived 1 yr and 22 months, respectively. Patients 5 and 6 had only limb defects. Craniofacial and neurologic manifestations of our longer-survival patients with severe craniofacial anomalies were microcephaly, encephalocele, micro- or anophthalmia, mental retardation, hydrocephaly, seizures, EEG abnormalities, impaired body temperature control, impaired vision, hypertonia, and other psychomotor deficits. Characteristic cutaneous manifestations seen in our patients were clefting, schisis, fibrous strings, ring constriction, lymphedema. pseudosyndactyly, and intrauterine amputation. Histologic examination of the amniotic bands attaching to the skin showed autolyzed amnion in patient 2, erosion of the band into upper dermis in patient 1, and fibrosis underlying the constricted areas in patient 5. Prenatal diagnosis by ultrasonography is possible in patients with severe craniofacial defects (patient 2). A brief review of the literature is offered.

Venous bridge used in free flap transfer for the lower leg in the presence of venous hypertension: a case report

Reconstruction with free flaps for the lower leg in the presence of venous thrombosis or venous hypertension has a high risk of failure. We describe the use of the contralateral leg for venous drainage through a pedicled skin bridge containing a tributary of the long saphenous vein. The recipient artery was a main artery of the ipsilateral leg. Two weeks later, once there was a well-established venous communication between flap and recipient site, the venous bridge was divided. Because the arterial inflow to the flap was not interrupted by the division of the skin bridge, the flap has good viability and good resistance to infection or ulceration 3 years later.

Design of a holographic lens for the infrared

Techniques are described for the construction of a holographic lens for focusing a collimated beam to a point. The lens is constructed in the visible for use in the near infrared. A major problem is to eliminate aberrations that result from the shift between the wavelength of construction and of use.

Stab wounds to the abdomen: failure of blunt probing to predict peritoneal penetration

A study was conducted to examine the usefulness of blunt probing for evaluation of penetrating abdominal trauma. Ten anesthetized adult beagles weighing 8 to 17 kg were sacrificed by ventricular fibrillation following a standardized resuscitation protocol. Immediately thereafter, the abdomen was shaved and ten stab wounds were placed in the abdomen of each dog with #11 blade. A separate individual probed the wounds sequentially with a cotton swab and predicted on the basis of this examination whether the wound penetrated the parietal peritoneum (deep) or not (superficial). The abdomen then was opened and reflected, by a midline incision, and peritoneal penetration was verified visually by two observers. Statistical analysis of data was performed using the z test for binomial proportions. Fifty-nine of the 100 wounds were found to penetrate the parietal peritoneum. Examiners predicted 35 correctly, but called 24 of 59 superficial. Thirty-eight of 41 superficial wounds were identified correctly; three were incorrectly called deep. Sensitivity was .59 (z = 1.432, P greater than .5); specificity was .93 (z = 5.466, P less than .001). Blunt probing may be a useful technique if peritoneal penetration is determined, but it is inaccurate in predicting peritoneal nonpenetration. If violation of the peritoneum is not determined with this technique, other methods must be used.

Nitrogen fixation ability of exopolysaccharide synthesis mutants of Rhizobium sp. strain NGR234 and Rhizobium trifolii is restored by the addition of homologous exopolysaccharides

Several transposon Tn5-induced mutants of the broad-host-range Rhizobium sp. strain NGR234 produce little or no detectable acidic exopolysaccharide (EPS) and are unable to induce nitrogen-fixing nodules on Leucaena leucocephala var. Peru or siratro plants. The ability of these Exo- mutants to induce functioning nodules on Leucaena plants was restored by coinoculation with a Sym plasmid-cured (Nod- Exo+) derivative of parent strain NGR234, purified EPS from the parent strain, or the oligosaccharide from the EPS. Coinoculation with EPS or related oligosaccharide also resulted in formation of nitrogen-fixing nodules on siratro plants. In addition, an Exo- mutant (ANU437) of Rhizobium trifolii ANU794 was able to form nitrogen-fixing nodules on white clover in the presence of added EPS or related oligosaccharide from R. trifolii ANU843. These results demonstrate that the absence of Rhizobium EPSs can result in failure of effective symbiosis with both temperate and subtropical legumes.

Three conditions in neonatal asphyxiating thoracic dysplasia (Jeune) and short rib-polydactyly syndrome spectrum: a clinicopathologic study

Clinicopathologic examination of eight patients with asphyxiating thoracic dysplasia (Jeune; ATD) disclosed two different types, which were designated as type 1 and type 2. Type 1 ATD was characterized by the presence of radiologically irregular metaphyseal ends and histopathologically irregular cartilage bone junction with patchy distribution of physeal zone of hypertrophy. Type 2 ATD showed radiologically smooth metaphyseal ends and histopathologically diffusely retarded and disorganized physes with smooth cartilage bone junctions. Examination of four patients with the "Verma-Naumoff" short rib-polydactyly syndrome showed many radiologic and pathologic features similar to those of type 1 ATD. Differential diagnosis of these three osteochondrodysplasias is discussed along with chondroectodermal dysplasia (Ellis-van Creveld), short rib-polydactyly syndrome type 1 (Saldino-Noonan), short rib-polydactyly syndrome type 2 (Majewski), and the new short rib syndrome reported by Beemer et al [1983].

The inhibitory effects of some adenosine analogues on transmitter release at the mammalian neuromuscular junction

An electrophysiological study was made of the effects of four adenosine analogues, 2-chloroadenosine (2-CIA), 5'-N-ethylcarboxamidoadenosine (NECA), L-N6-phenylisopropyladenosine (L-PIA), and 2-(p-methoxyphenyl)-adenosine (CV-1674) on neurotransmitter release in the mouse phrenic nerve - hemidiaphragm preparation. All four drugs decreased miniature end-plate potential frequency in a dose-dependent manner. Evoked transmitter release in the cut diaphragm preparation was depressed by 2-CIA and CV-1674 to a similar extent. The ability of theophylline to antagonize the inhibitory effect of CV-1674 on spontaneous transmitter release was also established. On the basis of these results, the rank order of potencies was: L-PIA greater than NECA greater than 2-CIA greater than CV-1674. A clear classification of receptor type could not be made, since the ratio of potencies of L-PIA and NECA was narrow. Different slopes of the concentration-effect curves for 2-CIA and CV-1674 compared with L-PIA and NECA suggest an additional component to simple agonist action in their overall effects.

Coverage of the degloved thumb with twin neurovascular island flaps: a case report

A simple and useful method is described for resurfacing a distal phalanx of the degloved thumb with twin neurovascular island flaps from the ulnar and radial aspects of the middle and ring fingers respectively. It provides protective sensation and an acceptable cosmetic result.

Magnetic resonance imaging of avascular necrosis of the femoral head

This study investigates the role of magnetic resonance imaging (MR) in identifying avascular necrosis (AVN) of the femoral head and in monitoring its therapy. The detection of AVN, particularly in its early stages, is imperative to give therapeutic intervention the best opportunity for successful management. The results of magnetic resonance imaging are compared with those of the standard diagnostic modalities in evaluation of patients with the lesion. Examinations were performed at 0.12T with a repetition time (TR) of 143 ms and times to echo (TE's) of 10 or 20 ms. This study represents a retrospective review of 90 hips which were examined in 45 consecutive patients. Of these, 52 hips were biopsied as part of treatment. MR was shown to be sensitive in the detection of AVN. Comparison of MR with radionuclide imaging showed comparable sensitivity and specificity. MR was also noted to be sensitive in the detection of early AVN. Preliminary results suggest that MR can monitor treatment of the affected hip, and may even be able to predict patient response to therapy. Although further work is necessary to determine the role of MR in the evaluation of the patient presenting with hip pain, MR is a sensitive method in detecting AVN and in monitoring its course in patients suspected of having the disease.

Stress hormonal response to exercise after sleep loss

While prolonged loss of sleep is unpleasant and demanding, it remains unclear if it blunts or enhances the physiological stress imposed by subsequent exercise. To investigate this, we deprived eight subjects of sleep prior to exercise to see if this altered the stress hormonal response to that exercise. In a first series of experiments, two fragmented nights of sleep preceded 30 min of heavy treadmill walking exercise. While sleep loss disturbed mood before and during exercise (p less than 0.05), it left stress hormonal levels (cortisol and beta-endorphin) in blood identical to control. In a second series, subjects performed light treadmill walking exercise for 3 h after 36 sleepless hours. As before, sleep deprivation disturbed mood before and throughout exercise (p less than 0.05), but failed to change blood levels of stress hormones. In both series, sleeplessness left heart rate, oxygen uptake, minute ventilation, and body core temperature unchanged in exercise. We conclude that sleep loss provokes psychological changes during subsequent exercise without measurably altering the stress hormonal response to that exercise.

Comparison of a videotape instructional program with a traditional lecture series for medical student emergency medicine teaching

An emergency medicine faculty has reported that the use of the videotape medium for presenting curricular material to medical students is both cost effective and well suited to the educational milieu of the emergency department. In order to compare the effectiveness of videotape instruction with that of a traditional lecture, groups of students received instruction in one topic by videotape and in another topic by lecture. The students' retention of material was tested by a multiple-choice examination administered ten days later. The students scored 76.1% (683 of 898 questions) on material taught by lecture and 76.2% (673 of 883 questions) on material taught by videotape (P greater than 0.7). We conclude that videotape instruction is as effective an educational tool as the traditional lecture for an emergency medicine course.

Distribution of ATPase-positive Langerhans cells in normal adult human skin

The distribution of ATPase-positive Langerhans cells (LC) was investigated in 117 specimens of normal adult human skin and mucosa taken from different areas of the body. Although there were significant variations in the numbers of LC in each area examined, skin from the face and neck contained the highest density of cells (976 +/- 30.93/mm2). The densities of LC in trunk skin (740 +/- 28.97/mm2), scalp (693 +/- 69.56/mm2) and arm or leg skin (640 +/- 40.95/mm2) were similar. Buccal mucosa had significantly fewer LC (567 +/- 42.94/mm2) than trunk skin, and sacrococcyx skin and palm and sole skin displayed the smallest number of these cells (267 +/- 56.14/mm2 and, 189 +/- 19.15/mm2 respectively). No ATPase-positive LC were detected in the centre of two corneal specimens.

Radiographic and histologic analyses of stress fracture in rabbit tibias

Sequential changes in remodeling of the internal structure of the tibia caused by controlled, excessive jumping and running were studied in 20 rabbits. Vascular changes and circulatory disturbances within the cortical bone occurred before osteoclastic resorption. Degeneration and necrosis of osteocytes due to circulatory disturbances also occurred. Periosteal new bone formation, found at and after 12 days of the experiment, was a compensatory reaction to support the tibia weakened by accelerated osteoclastic resorption. Small cracks appeared at the cement line and developed through the neighboring cement line of the haversian systems. At 21 days, incomplete fracture of the tibial cortex was found in two rabbits. Complete fracture through one side of the cortex was seen in one animal at the 50th day of the experiment. In this study, however, most of the tibias did not have visible fracture lines after a period of stressful exercise. This result suggests that most tibias adapt to changes in stress requirements through proper internal remodeling so that a complete fracture does not occur.

Goldenhar syndrome, anterior encephalocele, and aqueductal stenosis following fetal primidone exposure

Fetal exposure to primidone was associated with Goldenhar syndrome, hemifacial microsomia, tetralogy of Fallot, aqueductal stenosis, and anterior encephalocele in this male infant. No similar cases in anticonvulsant-exposed pregnancies were found on literature review, despite the increased incidence of other anomalies following such exposure. Goldenhar syndrome, especially related to rare central nervous system anomalies, is reviewed. Experimental production of hemifacial microsomia by a folic acid antagonist, triaxene, is mediated via hemorrhage in the fetus. Intraventricular hemorrhage was noted in this infant as were dilated lateral and third ventricles. The hemorrhagic diathesis and/or the folic acid depletion of newborns following fetal anticonvulsant exposure may have been the underlying mechanism.

Inspiratory muscle training in patients with chronic obstructive pulmonary disease

To investigate the effects of inspiratory muscle resistive loading training (IMT) on exercise performance in chronic obstructive pulmonary disease (COPD), 13 patients undergoing standard pulmonary rehabilitation were divided into control (n = 6) and experimental (n = 7) groups. Prior to training, we measured inspiratory muscle strength and endurance, resting pulmonary function, and exercise performance on a bicycle ergometer (a progressive test and an endurance test at two thirds of maximal work load). We then determined their resistive loads for training by measuring their 10-min maximal sustainable resistance. Training by patients in the experimental group involved inspiring against a predetermined resistive load. The control subjects breathed through a sham training tube, so that studies were performed in double-blind fashion. The training consisted of 15-min sessions twice daily for 4 wk. The IMT dramatically improved inspiratory muscle endurance--represented as either sustainable inspiratory pressure (SIP) or endurance time at 60% of maximal inspiratory mouth pressure (Pimmax) at functional residual capacity. The SIP of the trained group increased from 29 +/- 11 to 46 +/- 11% of Pimmax (p less than 0.005). Training slightly increased inspiratory muscle strength (p less than 0.05), as determined by Pimmax. In contrast, resting pulmonary function and performance of both progressive and constant-load exercise remained unchanged. We conclude that 4-wk IMT in a pulmonary rehabilitation setting improves inspiratory muscle endurance in patients with COPD without changing pulmonary function or exercise performance.

Detection of a thermostable brain antigen in the circulation of patients after cerebrovascular accident

Enzyme immunoassay was developed with a thermostable antigen of human brain and its corresponding antiserum of rabbit origin. Inhibition of this assay proved to be a sensitive technique for detection of this antigen in the circulation. Using the inhibition test, we tested 170 serum samples originating from 42 patients with cerebrovascular accident (CVA), 166 sera from 166 patients with other neurological disorders, and 56 sera from 56 normal subjects. Fourteen patients with CVA were found to be "positive' and 28 "negative'. Positive results in inhibition tests were first noted within 1-2 days after CVA and they appeared to decline to negative values within 3-5 weeks after CVA. None of the sera from subjects without CVA were positive.

A student emergency medicine clerkship that uses new information technologies

The effective teaching of clinical emergency medicine to medical students requires efficiency in the management of both student and faculty time. Presented is a course outline that makes use of the following elements to structure and augment clinical time in the emergency department (ED): Videotape to present a 19.7-hour series of faculty-produced lectures covering a "core" emergency medicine curriculum. A microcomputer to facilitate staggered scheduling of clinical time. A microcomputer test generation program that permits a secretary to formulate, administer, and grade a different final exam with each rotation. Computer-assisted recordkeeping for faculty evaluation of a student's clinical performance. Once established, this program can be administered with fewer than five faculty hours per month assisted by a part-time (25% full-time equivalent) clerical coordinator. The total cost for the instructional program is $86.37 per student using the new technologies, and $144.15 per student when presenting the same program using traditional teaching techniques. The use of new technologies in student teaching will therefore result in significant savings.

A "new" lethal multiple congenital anomaly syndrome: joint contractures, cerebellar hypoplasia, renal hypoplasia, urogenital anomalies, tongue cysts, shortness of limbs, eye abnormalities, defects of the heart, gallbladder agenesis, and ear malformations

Three cases of a lethal malformation syndrome with severe visceral anomalies were seen in two families and include one pair of sibs. The predominating external manifestations are mesomelic dwarfism, micrognathia, V-shaped upper lip, microglossia, thick alveolar ridges, ambiguous genitalia, webbed neck, highly arched palate, clubfeet, fused fontanelles, inclusion cysts of the tongue, four-finger creases, digital anomalies, apparently low-set ears, widely spaced nipples, and dislocated thighs and forearms. The internal findings include oligopapillary renal hypoplasia, severe congenital heart defect, cerebellar hypoplasia, pulmonary hypoplasia, hypoplastic larynx, and hypoplastic gallbladder. Other findings from the two autopsies and one clinical investigation not documented in all three patients include unilobar lungs, hydrocephalus, cataracts, microphthalmia, polydactyly, islet cell hyperplasia, suprapubic skin crease, urethral anomalies, and a decreased number of turns of the cochlea. The hypoplasia seen in the several affected organs is similar to the disordered development seen in experimental models of branching epithelial morphogenesis in which mesenchymal-epithelial interaction has been disrupted.